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The Pill | Article

Current Pill Use

(Originally published in 2003.)

Is it safe? How do prescriptions differ? Will there be a male pill?
Read this Q&A with obstetrician/gynecologist Daniela Carusi, M.D., the director of general gynecology at Brigham & Women's Hospital in Boston. Dr. Carusi also teaches obstetrics, gynecology and reproductive biology at Harvard Medical School.

Is the Pill safe today?
For the majority of fertile women, specifically young women and non-smokers over the age of 35, oral contraceptive use is safer than pregnancy. The Pill carries very small risks of serious events, such as blood clots, heart attack, or stroke, which are outweighed by the excellent contraceptive and non-contraceptive benefits. Only 1/10,000 to 1/100,000 women who use the Pill will suffer a serious health consequence. In the United States the Pill is available only by prescription, in part so that physicians may screen women at higher risk for these events and offer alternate forms on contraception. However, it is felt to be safe enough to justify over-the-counter use in other countries, and many people have advocated such availability in the U.S. as well.

How should a woman determine which Pill to take?
Currently almost all women are started on "low dose" pills, which contain between 20 and 35 micrograms of estrogen. There are many hormone combinations to choose from at these doses, and individual patients may notice subtle differences in side effects between them. Major considerations include past success or failure with a particular Pill brand, and financial cost to the patient.

A woman can tailor her Pill choice to her individual needs. Though most pills are likely to help with acne and abnormal hair growth, newer formulations of the Pill have been advocated for treating these specific conditions. Some women may have more breakthrough bleeding or spotting on the lowest-dose (20 microgram) pills, and may need to raise the dose to avoid these side effects. Certain patients, such as those at risk for clotting problems and women who are breastfeeding, may need to avoid estrogen all together and take a "minipill," which contains progesterone only.

Does the Pill affect later fertility?
Though ovulation may be delayed when a woman first stops taking oral contraceptives, there is no evidence that long-term fertility is affected. In fact, there is some evidence that women who have never been pregnant and use the Pill will have a lower risk of infertility later on. Women who have irregular periods and fail to ovulate before starting oral contraceptives may continue to have this problem after stopping the Pill.

Can women get pregnant while taking the Pill?
If the Pill is used "perfectly" by 1,000 women, one of them will become pregnant after one year. In reality, many women may forget pills, take them at the wrong time of day, or delay starting a new pack of pills after the last pack has finished. Missing or delaying pills increases the risk of ovulation, fertilization, and pregnancy. Because of this, with "typical" use up to 5% of pill users will become pregnant in one year.

Does the Pill have serious life-threatening side effects, such as blood clots, strokes and heart attacks?
Overall, the risk of developing a serious blood clot is approximately 1/10,000 and the risk of developing a heart attack or stroke is approximately 1-5/100,000. Only a small fraction of these cases are fatal. In comparison, approximately one of every 10,000 women giving birth in the United States will die from a complication. These risks have not been eliminated because they are linked to hormone exposure, and exist with pregnancy as well.

By far the most important condition that predisposes a patient to a serious side effect is cigarette use, and patients on the Pill are strongly encouraged to stop smoking. Patients with significant risk factors for cardiac disease or clotting disease should also avoid the Pill. Risk factors include significant hypertension, advanced diabetes, or a personal history of these events. Patients with a strong family history for these conditions should be screened, but the benefits of Pill use may still outweigh the risks for these women.

How does the Pill protect women from cancer in the ovaries and uterus?
During an ordinary menstrual cycle the ovary is stimulated and its cells grow and divide. One of the Pill's important effects includes quieting the ovary and preventing ovulation. By slowing cell division in the ovary over a period of time, the risk of cancer goes down.

On the other hand, the beneficial effect to the uterus comes directly from the progesterone component of the birth control pill. Progesterone directly slows tissue growth in the lining of the uterus. This causes a woman's menstrual periods to become lighter or even to stop, and decreases the risk of developing a cancer.

If condoms are used to prevent sexually transmitted diseases, doesn't taking the Pill in addition provide too much contraception?
Many people will argue that there is no such thing as "too much" contraception. There is a low chance that a condom will break, slip, or have a defect in the latex. However, once one of these problems occurs, the couple has essentially no contraception. In that case, having a reliable backup method is very important.

Why isn't there a male birth control pill?
Treating men with hormones that prevent fertility is likely to cause impotence or other intolerable side effects. While men would benefit from having more control over their own fertility, this is the most likely reason why attempts to develop a male "Pill" have been unsuccessful.

Some mothers start their daughters on the Pill long before they are sexually active -- just in case. What are the implications of starting Pill use in the early teens?
If a young girl starts the Pill before puberty she may adversely affect her growth or normal pubertal development. However, once a teenager begins menstruating on her own the risks of the Pill are not higher than those for an older adult. Important considerations for teenagers include adherence to a daily dosing regimen and the importance of using condoms for the prevention of sexually transmitted infections. The Pill has the same health benefits for teenagers as for adults, including more regular and less painful periods, prevention of ovarian cysts, reduction of acne and abnormal hair growth, and a positive effect on bone growth.

What questions should women interested in taking the Pill be asking their doctors?
With the help of their doctors women should develop a personal risk/benefit profile for using oral contraceptives. Women with irregular menstrual cycles, heavy or painful periods, endometriosis, abnormal hair growth, acne, ovarian cysts, and benign breast disease may obtain significant health benefits from the Pill which they may not gain from non-hormonal alternatives. On the other hand, women at significant risk for heart disease or clotting may need to avoid oral contraceptives. Therefore, it is important for a woman to review her complete medical and family history with her doctor. Women who smoke should factor this in to their risk profile, and discuss realistic methods of smoking cessation. The balance between risks and benefits will differ for every patient, though for the vast majority of women the risks are outweighed by the contraceptive benefit alone.

Because "perfect use" is important to the Pill's effectiveness, it is important for a woman to receive detailed instructions on starting and continuing the medication. Women who have trouble remembering to take the Pill every day should discuss other forms of the medication, such as the patch, injections, or the vaginal ring.

Visit the U.S. National Library of Medicine and National Institute of Health's MEDLINE Plus Web site for more information on pregnancy, contraception, hormone replacement therapy, and other women's health topics.

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